Descriptive analysis of a 1:1 physiotherapy outpatient intervention post primary lumbar discectomy: one arm of a small-scale parallel randomised controlled trial across two UK sites

Physical therapies after surgery for lumbar disc herniation- evidence synthesis from 55 randomized controlled trials (RCTs) and a total of 4,311 patients

Introduction

The role of physical therapy after lumbar disc herniation surgery is unclear.

Research question

To determine the impact of physical therapy following LDH surgery (Q1), investigate the effects of activity limitations (Q2), the best time to start physical therapy (Q3), the significance of supervised physical rehabilitation (Q4), the types of physical therapies used (Q5), and the role of additional approaches, such as education, manipulation, and acupuncture, in enhancing the effectiveness of rehabilitation (Q6).

Material and methods

This systematic review searched three databases from inception to May 2024. Independent reviewers screened studies, assessed and extracted data, and critically appraised the quality of the available evidence.

Results

This systematic review included 55 randomized controlled trials with 4311 patients. We demonstrated that physical therapy after lumbar disc surgery is effective in alleviating pain and improving function and quality of life after surgery for lumbar disc herniation. Exercise regimens aimed at enhancing the endurance, flexibility, and strength of the back musculature are generally efficacious, with the exception of exercises involving neural mobilization. Imposing limitations on physical activity does not yield substantial advantages; however, the occurrence rate of potential complications, the optimal timing for initiating activity and the cost-effectiveness of supervised exercise remain subjects of ongoing discourse. Concurrent application of manual therapy, acupuncture, educational interventions, and behavioral and occupational therapy has the potential to augment outcomes.

Discussion and conclusion

Physical therapy improves functional outcomes after lumbar disc surgery. Further studies should address its safety, and cost-effectiveness, and provide dissemination and applicability tools.

Rehabilitation and lumbar surgery: the French recommendations for clinical practice

BACKGROUND

Indications and techniques of rehabilitation differ widely across types of lumbar surgery, including timing (before or after surgery) and prescriptions (surgeons but also medical or paramedical professionals).

OBJECTIVES

This project aimed to build consensual recommendations for practice in this context.

METHODS

The SOFMER methodology was used to establish recommendations for physical medicine and rehabilitation: a steering committee defined the types of lumbar surgery involved and developed the main questions to be addressed; a scientific committee performed a literature review for grading evidence and proposed the first version of recommendations, which were discussed during a dedicated session at the national Physical and Rehabilitation Medicine congress; then an e-Delphi method with cross-professional experts was used to finalise recommendations and reach a multidisciplinary consensus.

RESULTS

The main questions developed were the value of rehabilitation before and after surgery, timing and type of rehabilitation, benefit of supervision and instrumental rehabilitation, value of patient education, and complementary interventions concerning rehabilitation for discectomy, fusion, and disc prosthesis (excluding decompression for spinal stenosis). The literature review identified 60 articles, but for several of the questions, no article in the literature addressed the issue. The multidisciplinary scientific committee analysed the literature and addressed the questions to propose the first version of a set of 23 recommendations. The congress session failed to answer all questions or to reach consensus for all items. After a three-step e-Delphi, 20 recommendations were retained, for which consensus among experts was reached. The recommendations are applicable only to patients without a neurological lesion.

CONCLUSIONS

These recommendations provide important and consensual knowledge to assist clinicians in decision-making for rehabilitation in lumbar surgery. Despite many of the recommendations relying exclusively on expert opinion rather than published evidence, this approach is an important advance to improve concordance among healthcare professionals.